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Sniffing at Empty Nose Idea

Surgery to remove nasal tissue is being blamed for a debilitating syndrome. But specialists hotly debate whether the procedure is to blame.


WASHINGTON — Eugene Passer had never heard of the turbinates, a set of tissues that lie in the nasal cavity. Then a doctor removed much of them, he says, and life became a mess.

A New York college professor, Passer says he can no longer teach organic chemistry labs because he cannot detect the smell of dangerous fumes. Head and eye pains are constant. On cold days, the air leaves him dizzy and weak. He rarely travels anywhere without a humidifier, which eases some of his symptoms.

"I'd say a large part of my life has been destroyed--it's that simple," Passer said.

Now, sinus specialists are engaged in a contentious debate about what causes the problems reported by Passer, and by a small but increasingly vocal set of other patients. At professional conferences, one group of physicians has been trying to build a case that removal of too much turbinate tissue can cause an illness the doctors call "empty nose syndrome," which they say has appeared only in recent years.

Other specialists doubt that the syndrome exists. They say that turbinates have been removed for 100 years with few problems and that the pain patients report must come from some other cause.

The debate may sound arcane, but more than 160,000 people had turbinate tissue removed in 1996, the last year for which the Centers for Disease Control and Prevention has statistics. Some doctors think that the true number is far higher, and that it is rising.

People who think they have empty nose syndrome say it was a variety of complaints that initially prompted them to see a doctor. A few had structural problems in the nose, such as a deviated septum. Some had nasal growths, or polyps, that had to be removed. Most were seeking relief from the headaches and breathing problems that often come from sinus inflammation, a common complaint that accounts for nearly 10.8 million doctor visits each year, more than for asthma and about the same as for ear infections.

But these patients claim that the real trouble started after a doctor treated them by removing turbinate tissue, most often in an attempt to make breathing easier.

Now, Tom Brown, a New York businessman, says he feels like he has a permanent case of the flu. Bradley Santos, a federal worker in Washington, D.C., complains of headaches, and he says he has lost his senses of smell and taste.

"This problem just makes life a kind of hell," said Elizabeth Monroe of Seattle, who left her paralegal job to start a new business at home so she could surround herself with humidifiers and air filters.

Among nose specialists, empty nose syndrome has become a hot topic. When doctors from around the world gathered in Washington, D.C., last fall at Nose 2000, the quadrennial meeting of the International Rhinologic Society, they held two separate debates on whether the syndrome exists. The issue is also on the agenda next week at a conference of the American Rhinologic Society and eight other professional groups in Palm Desert.

"Every time we talk about it, the room is packed," said Dr. William H. Friedman, a St. Louis ear, nose and throat specialist, and an empty nose doubter.

"I call it the empty head syndrome," he said.

Although patients may be in pain, the notion that they have a discrete illness is an empty-headed one.

The debate shows that, at a time when scientists have deciphered the microscopic genes within our cells, there is still plenty to learn about the nose in front of our face.

Turbinates sit in three pairs in the nasal cavity. Most specialists believe they exist for several important reasons.

Cilia and mucus on the turbinates act as a defense against foreign agents, trapping airborne particles and other unwanted matter. They create a "weather pattern" in the nose that warms and humidifies inhaled air so that breathing cold air is comfortable.

Some doctors say turbinates also help with the act of breathing. Imagine water trickling thinly out of a garden hose; a thumb placed over the nozzle would make the water squirt farther. The turbinates may do something similar in the nose, forcing air through the cavities in ways that make it satisfying to take a breath.

Doctors have been removing turbinates for at least a century, often because they were diseased, inflamed or causing breathing problems. But the surgery was not common. To reach the turbinates, doctors had to push their instruments through the nostrils, which offer a poor line of sight. At times, they cut pathways into the sinuses, often by punching through the underside of the upper lip.

Then, in 1984, Dr. David W. Kennedy of the University of Pennsylvania began introducing U.S. doctors to an Austrian procedure that used an endoscope. A kind of telescope that attaches to a video monitor, the endoscope allowed surgeons to see the nasal passages far more clearly and to work there more comfortably.

As a result, doctors began performing more nasal surgeries.

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